With the aging of the population and advances in medical technology, families are increasingly asked to make decisions regarding the end-of-life care of older loved-ones with critical illness. Intracerebral hemorrhage (ICH) is a common and severe type of stroke with a high risk of early mortality, though good functional recovery is possible in some survivors. The decision to pursue either full intensive or comfort care occurs very early during the course of ICH treatment, with one-third of ICH patients having a do-not-resuscitate (DNR) order written within the first 24 hours. There is significant variability in use of DNR orders and withdrawal of life sustaining treatment after ICH. Many factors likely drive this variability, including family values and belief systems, pre- existing illness, physician's estimate of prognosis and the family's understanding of the prognosis. The rapid onset of symptoms, reliance on surrogate decision makers, uncertain prognosis, and early nature of the decisions suggest that the process of end-of-life decision making after ICH is likely to be distinct from that of other conditions. The long-term goal of this career development award is to promote the candidate's development into a clinical and research leader working to improve the process of end-of-life decision making in acute neurological disease. The aims of this project are 1) To assess determinants of variability in physician prognostic estimates and recommendations to withdraw life sustaining treatment 2) To describe the factors that influence surrogate end-of-life decisions about ICH and their satisfaction and regret surrounding these decisions;and 3) To identify modifiable determinants of surrogate decisional satisfaction and decisional regret surrounding ICH end-of-life care. This project will combine a national survey of physicians with interviews and surveys of surrogate decision makers from two distinct health care systems in order to understand the process of end-of-life decision making after ICH from the perspective of the physician and the family. The candidate is committed to a career as a rigorously trained clinical investigator and requires additional training in order to accomplish his long term goal of improving end-of-life care for older individuals facing acute neurological disease. A detailed career development plan will promote the candidate's development of expertise in decision science, qualitative and mixed-methods research, advanced quantitative analysis, as well as palliative and end-of-life care. The career development plan consists of a multidisciplinary team of experienced mentors and advisors who will oversee a range of formal coursework and practical experiences in these areas to ensure the candidate's future success. Superb resources of a top university and a mentoring team with demonstrated success in developing junior investigators in these topic areas makes the University of Michigan an ideal environment for this project. PUBLIC HEALTH RELEVANCE: Making decisions about the medical care of a loved-one with acute brain hemorrhage is a difficult and frightening time for families. This project will work to improve the processes that doctors and families use to make these decisions in the future.